Using Quality Improvement to Reduce Loss to Follow-Up in Pediatric Patients With Type 1 Diabetes

BACKGROUND: Quarterly diabetes clinic visits are recommended for pediatric patients with type 1 diabetes (T1D). Lower rates of clinic visit attendance are associated with higher hemoglobin A1c (HbA1c) levels. We aimed to reduce the proportion of patients younger than 18 years with T1D who were lost to follow-up (LTFU) from a baseline of 38% to 20% in 18 months. METHODS: A multidisciplinary team consisting of endocrinologists, clinic leadership, and program managers reviewed the existing scheduling process and created a driver diagram for improvement. LTFU was defined as the last clinic visit being more than 6 months prior. Multiple Plan-Do-Study-Act (PDSA) cycles were conducted to evaluate quality improvement (QI) interventions that included same-day scheduling of return visits by medical assistants, online scheduling via patient portal, and identification of and focused outreach to the LTFU cohort. The proportion of patients LTFU was analyzed monthly via statistical process control charts (p-charts). Planned data disaggregation by patient demographics and HbA1c levels was used to ensure existing disparities did not worsen. RESULTS: We successfully reduced the proportion of patients LTFU from 38% to 15% by 18 months, and improvement was sustained at 27 months. Improvement in the proportion LTFU was seen across different patient demographics (eg, age, sex, race and ethnicity, language for care, health insurance) and HbA1c categories (<7%, 7%-9%, ≥9%) with a reduction in existing disparities. CONCLUSIONS: Using a PDSA QI framework, simplifying the visit scheduling process and implementing changes in small, iterative cycles led to reduction in the proportion of pediatric patients with T1D who were LTFU.